Medicare Eligibility and Changes in Coverage, Access to Care, and Health by Sexual Orientation and Gender Identity

Key Points Question Is Medicare eligibility associated with reduced disparities in health insurance coverage, access to care, and self-reported health status among individuals by sexual orientation or gender identity? Findings This cross-sectional study using regression discontinuity found that Medicare eligibility at age 65 years was associated with larger increases in self-reported health status among respondents identifying as lesbian, gay, bisexual or another sexual minority identity (LGB+) than those identifying as heterosexual, but smaller increases in insurance coverage and access to care. Yet in the US states with the highest preexisting disparities, LGB+ individuals reported larger improvements in insurance coverage, access, and health status than did heterosexual individuals. Meaning These findings indicate that Medicare eligibility is associated with improved self-reported health among LGB+ adults compared with heterosexual adults; additionally, in states with larger disparities, Medicare may reduce disparities in insurance coverage and access to care between the groups.

D. Share in good or better self-reported health Note: For each panel, we plot the share of the study population, in the Northeastern census region of the United States, that report each outcome by age in years separately for heterosexual and LGB+ respondents during the study period (2014)(2015)(2016)(2017)(2018)(2019)(2020)(2021).The states comprising the US Northeast include: Connecticut, Massachusetts, Rhode Island, Vermont, New York, New Jersey, and Pennsylvania (Maine and New Hampshire were excluded from our sample due to not reporting SOGI data in the BRFSS for any of our study years).For illustrative purposes, the line of best fit is based on a local regression model using the optimal bandwidth selected by the RD Honest model for each outcome separately for heterosexual and LGB+ respondents (see eMethods in Supplement).The Medicare eligibility age threshold at 65 years is represented by the dotted black line.

eFigure 10. Smoothness tests for the number of respondents by sexual orientation
Note: The number of respondents in the overall sample and in each subgroup by sexual orientation are collapsed by age across years 2014-2021 and plotted for ages 51-79.We use the RDHonest package, consistent with our regression discontinuity approach for the primary and secondary analyses, to assess whether there were any discontinuities in the number of numbers at age 65 in our overall sample or for any subgroup.The reported point estimate reflects the discontinuity at age 65 and 95% confidence intervals are bias-adjusted from RDHonest.b Adjusted discontinuity estimates are in percentage points and report the RD Honest estimates and bias-adjusted confidence intervals.We use the same approach to estimate the discontinuities in the missingness of our primary outcomes as we use to estimate the discontinuities of our outcomes in our main analyses.

Change at age 65 years
Expected Mean, % a Adjusted discontinuity (95% CI) b

Full Sample
In insurance coverage, % 99.3 0.16 (0.03 to 0.29) In usual source of care, % 99.6 0.02 (-0.05 to 0.10) In cost barriers to seeing a physician in the past year, % 99.8 0.01 (-0.07 to 0.09)    b LGB+ stands for lesbian, gay, bisexual, or another sexual minority identity respondents.c Disparity is the percentage point (pp) difference calculated by subtracting the mean outcome for LGB+ respondents from the mean outcome of HE respondents (or the reverse in the case of the "unable to see doctor in the past year due to cost" outcome where lower values for this outcome are more favorable).The mean disparity is calculated for each state as the arithmetic mean of the pp differences for the four outcomes.States are ranked from those with the highest mean disparity to those with the lowest mean disparity.These ten states were identified as the highest disparity states based on differences between heterosexual and LGB+ respondents aged 51-55 years old, as opposed to respondents ages 51-64 years old in eTable 9.The expected means contain the counterfactual outcome at age 65 years in the absence of treatment (the expected outcome at 65 years without Medicare).c Adjusted discontinuity estimates are in percentage points and report the RD Honest estimates and bias-adjusted confidence intervals (refer to Methods sections for more detail on the statistical model).

eFigure 11. Smoothness tests for the number of respondents by gender identity
Note: The number of respondents by gender identity are collapsed by age across years 2014-2021 and plotted for ages 51-79.We use the RDHonest package, consistent with our regression discontinuity approach for the primary and secondary analyses, to assess whether there were any discontinuities in the number of numbers at age 65 in our overall sample or for any subgroup.The reported point estimate reflects the discontinuity at age 65 and 95% confidence intervals are bias-adjusted from RDHonest.Column contains the expected mean at age 65 years, which is based on the local linear association between age and the outcome in each row.The expected means contain the counterfactual outcome at age 65 years in the absence of treatment (the expected outcome at 65 years without Medicare).

Weighted study pop. characteristics and Medicare age-related discontinuities
a Columns contain weighted proportions in percentages (raw counts are available in Table1

eTable 4. Differences-in-discontinuities in study outcomes at the national level and among "high disparity" states Outcome Expected difference at 65 a Difference-in- discontinuity (95% CI) b Panel A. Full sample
a The expected difference subtracts the expected mean for heterosexual adults from the expected mean of LGB+ adults and represents the expected disparity by sexual orientation at age 65. b The difference-in-discontinuity estimates are in percentage points and produced from a linear regression analog to RDHonest (see eMethods).eTable 5.

Differences by sexual orientation in share insured for 51-64 year-olds by state
a HE stands for heterosexual respondents.bLGB+stands for lesbian, gay, bisexual, or another sexual minority identity respondents.c Disparity is the percentage point (pp) difference calculated by subtracting the mean outcome for LGB+ respondents from the mean outcome of HE respondents.States are ranked from those with the highest mean disparity to those with the lowest mean disparity.States selected as one of the top-ten "high disparity" states are highlighted in gray.eTable 6.

Differences by sexual orientation in usual source of care for 51-64 year-olds by state Sample size, N Share with a usual source of care, %
a HE stands for heterosexual respondents.bLGB+standsfor lesbian, gay, bisexual, or another sexual minority identity respondents.cDisparity is the percentage point (pp) difference calculated by subtracting the mean outcome for LGB+ respondents from the mean outcome of HE respondents.States are ranked from those with the highest mean disparity to those with the lowest mean disparity.States selected as one of the top-ten "high disparity" states are highlighted in gray.eTable 7.

Differences by sexual orientation in cost barriers for 51-64 year-olds by state Sample size, N Share unable to see doctor due to cost, %
a HE stands for heterosexual respondents.bLGB+standsforlesbian, gay, bisexual, or another sexual minority identity respondents.cDisparity is the percentage point (pp) difference calculated by subtracting the mean outcome for HE respondents from the mean outcome ofLGB+ respondents.States are ranked from those with the highest mean disparity to those with the lowest mean disparity.States selected as one of the top-ten "high disparity" states are highlighted in gray.eTable 8.

Differences by sexual orientation in good or better health for 51-64 year-olds by state Sample size, N Share in good or better health, %
a HE stands for heterosexual respondents.bLGB+standsforlesbian, gay, bisexual, or another sexual minority identity respondents.cDisparity is the percentage point (pp) difference calculated by subtracting the mean outcome for LGB+ respondents from the mean outcome of HE respondents.States are ranked from those with the highest mean disparity to those with the lowest mean disparity.States selected as one of the top-ten "high disparity" states are highlighted in gray.©2024Gavulic KA et al.JAMA Health Forum.eTable 9.

Mean disparities in the top ten "high disparity" states between heterosexual and LGB+ respondents, ages 51-64
a HE stands for heterosexual respondents.bLGB+standsforlesbian, gay, bisexual, or another sexual minority identity respondents.cDisparity is the percentage point (pp) difference calculated by subtracting the mean outcome for LGB+ respondents from the mean outcome of HE respondents (or the reverse in the case of the "unable to see doctor in the past year due to cost" outcome where lower values for this outcome are more favorable).The mean disparity is calculated for each state as the arithmetic mean of the pp differences for the four outcomes.States are ranked from those with the highest mean disparity to those with the lowest mean disparity.©2024Gavulic KA et al.JAMA Health Forum.eTable 10.

Mean disparities in the top ten "high disparity" states between heterosexual and LGB+ respondents, ages 51-55 Share insured, % Usual source of care,% Unable to see doctor in the past year due to cost, % Good or better health, %
a HE stands for heterosexual respondents.

Panel C. Lesbian, Gay, Bisexual, or Another Sexual Minority (LGB+) Individuals
a All estimates are unweighted.bColumn contains the expected mean at age 65 years, which is based on the local linear association between age and the outcome in each row.The expected means contain the counterfactual outcome at age 65 years in the absence of treatment (the expected outcome at 65 years without Medicare).cAdjusted discontinuity estimates are in percentage points and report the RD Honest estimates and bias-adjusted confidence intervals (refer to Methods sections for more detail on the statistical model).eTable12.

Medicare eligibility age-related discontinuities in coverage, access, and self- reported health among married individuals by sexual orientation at the national level a
Column contains the expected mean at age 65 years, which is based on the local linear association between age and the outcome in each row.The expected means contain the counterfactual outcome at age 65 years in the absence of treatment (the expected outcome at 65 years without Medicare).c Adjusted discontinuity estimates are in percentage points.
a All estimates are unweighted.b

Medicare eligibility age-related discontinuities in coverage, access, and self-reported health by sexual orientation in the period post-Obergefell v. Hodges at the national level a
Column contains the expected mean at age 65 years, which is based on the local linear association between age and the outcome in each row.The expected means contain the counterfactual outcome at age 65 years in the absence of treatment (the expected outcome at 65 years without Medicare).c Adjusted discontinuity estimates are in percentage points. b

Medicare eligibility age-related discontinuities in coverage, access, and self- reported health by gender identity a
Column contains the expected mean at age 65 years, which is based on the local linear association between age and the outcome in each row.The expected means contain the counterfactual outcome at age 65 years in the absence of treatment (the expected outcome at 65 years without Medicare).c Adjusted discontinuity estimates are in percentage points.
a All estimates are unweighted.b

Panel C. Lesbian, Gay, Bisexual, or Another Sexual Minority Identity (LGB+) Individuals
Column contains the expected mean at age 65 years, which is based on the local linear association between age and the outcome in each row.The expected means contain the counterfactual outcome at age 65 years in the absence of treatment (the expected outcome at 65 years without Medicare).c Adjusted discontinuity estimates are in percentage points and report the RD Honest estimates and bias-adjusted confidence intervals (refer to Methods sections for more detail on the statistical model).
a All estimates are survey weighted.b eTable 16.

Panel C. Transgender and Gender Diverse Individuals
Column contains the expected mean at age 65 years, which is based on the local linear association between age and the outcome in each row.
a All estimates are survey weighted.b